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mcap -> New Website (May 25, 2000 4:57:00 AM)
To the group: There is a new website [URL=http://www.clinicaltrials.gov]www.clinicaltrials.gov[/URL] They list current trials underway. There are four for the low back. One is studying psychosocial intervention for acute low back pain. We might be in trouble!!!!! Another one is [URL=http://www.centerwatch.com.]www.centerwatch.com.[/URL] There are quite a few low back studies on this one. There doesn't seem to be much in the way of PT research for the Low Back anywhere. Many of the studies are run by physicians who will use "the usual care" as a conservative treatment control. Of course I think that the usual care will consist of the same tired physical therapy routines of ab and extensor strengthening along with posture and maybe stretching. Of course we will not come out looking very good but it is our fault for letting the MDs dictate what PT is during the studies. And it is our fault because therapists don't seem to care about this problem. Make no mistake....the spine is the most common disorder encountered in outpatient practices. If we do not do a better job we will loose them!!!

Barrett -> Re: New Website (May 25, 2000 6:58:00 AM)
In the latest issue of NEWS-Line for Physical Therapists there is a report entitled "State of Mind May Contribute More to Low Back Pain Than Torn Discs." It will be published in "Spine" in December. This details once again the prevelance of false positive MRIs that focus on the disc. Of course, it seems not to address other possible diagnoses that are closely correlated to a rise in sympathetic tone, so I've got to wonder about this "State of Mind" comment. One thing remains, however, and that is the McKenzie community's silence on the matter of false positives. Maybe that will change here. ------------------

mcap -> Re: New Website (May 25, 2000 8:52:00 AM)
Barrett: You seem to pass up no opportunity to knock McKenzie. Could this be a result of your friendship and relationship with Stanley Paris?????????????? As for McKenzie and false positives....not only did they have something to say about it...they did a great study!!! Donelson, et al. "A prospective study of centralization of lumbar and referred pain. A predictor of SYMPTOMATIC discs and annular competence." Soine 22, 10, 1115-1122. In this study, patients with multiple positives on MRI or inclonclusive MRIs underwent a McKenzie eval to determine what discs were symptomatic. Many of these patients ended up having false positive disc lesions. THIS WAS ACKNOWLEDGED and dealt with!!! The Mckenzie therapist was able to predict whether or not the pain was discogenic, the level of the lesion, anuular contaiment or not, and he had to draw the fissure. In most areas, the specificity and sensitivity were close to 90% when compared to discogram. Not only have they acknowledged false positives, they have come up with a way to determine false positives clinically. Furthermore, they have validated it. Your assertions are completely without basis and I am curious as to your bias.

Barrett -> Re: New Website (May 25, 2000 11:08:00 AM)
mcap, Your presumption that my relationship with Paris has anything whatsoever to do with my opinion of McKenzie’s work is way off base. I trained with Stan in the mid 70s, and there is virtually nothing about my philosophy of care or method of management today that reflects his influence or his theoretical bent. This includes his opinion of McKenzie’s practice. Stan remains my friend however. My problem with Donelson’s study is the tacit assumption that the loading strategies of the McKenzie regimen of testing have no significant or meaningful effect on the nervous tissue that they obviously move. As Breig states in Spine, “ It may be deduced from these studies that the once popular concept of lumbosacral root pathology, that of a simple nerve root compression due to disc prolapse, is barely tenable. Compression implies bilateral pressure or circumferential squeezing. Yet the evidence points to an increased resting tension due to diversion of the root from its normal path, with unilateral pressure in certain postures when the tension is further increased. “Biomechanical Considerations in the Straight-Leg-Raising Test” Breig et al Spine Vol. 4 No.3 If some disc lesions when moved are symptomatic and others are not (and this is certainly true) the question, “Why is that?” might be considered. Donelson’s study didn’t answer that. Might it be because of the influence of factors beyond the connective tissue? This is something I find that community hesitant to discuss, and, commonly, dismissive of those of us willing to ask such a question. ------------------

mcap -> Re: New Website (May 26, 2000 8:28:00 AM)
Barrett: I am not hesitant to discuss your theories but I must disagree with you yet again. First and foremost, your original contention was that McKenzie was silent on the matter of false positives. I gave you a study that disproved your contention and now you are talking about a different criticism alltogether!! What was your point. You said they didn't acknowledge false positives and clearly they have. Claiming that they don't acknowledge neural tension is a different claim and does not support your original contention. It seems that you are contending that neural attention is affected by the disc and by the McKenzie loading strategies. Two this I would say two things..... First, how do you explain the discography results??? By sticking a needle into the disc how are you affecting neural tension?? The study compard the results to discograhpy and the results were solid. If you expand your definition far enough, neural tension could be assumed to be the cause of ALL pain. It isn't. Second, let's say that the disc is affecting neural tension in some fashion. What does it matter. The pain behaves and is predicitable in a manner described by McKenzie. McKenzie has repeatedly stated that the ultimate source of pathology does not matter. If it behaves like a derrangement then it is treatable as such. It seems like you have a ax to grind with the institute. You have posted repeatedly to their on-line study group to make your claims. You call for evidence based practice. They have done more research than any other PT intervention. They regularly discuss research favorable or unfavorable. How come you are not so active against the theories of the osteopathic PTs. Where is your questioning of Upledger or Jones??? Why is it always McKenzie. -mcap

Barrett -> Re: New Website (May 27, 2000 4:38:00 AM)
mcap, I'll stick with my assessment of Donelson's article. I posted a total of six times to the McKenzie list many months ago and nothing since, so your description of my activity there is not accurate. Anybody who suggests that I haven't been equally critical of the crainial methods and others in that community hasn't been paying attention. ------------------

Andrew M. Ball, MS, PT -> Re: New Website (May 27, 2000 6:21:00 AM)
Mcap, I don't know all that much about the McKenzie research other than to say that of what I've read, I've not been all that much impressed. They do try to deal with criticism that's true, but with a few notable exceptions its generally sloppy stuff and the conclusions are sometimes leaps of faith. Not exactly NEJM quality, but hey . . . at least they bother to try to put something out. That desearves them a little bit more respect than Upledger and Jones . . . but I'm not so sure that biased publications with inflated scientific assumptions is all that ethical either. The bottom line is that not much of the technique of orthopedic PT has been show to be terribly effective OVER NATURAL HISTORY OF RECOVERY, so this whole discussion is kind of moot. It's hard not to argue that the McKenzie group has the "best" research . . . it's for all intents the ONLY research on LBP intervention technique. I've found much of the rhetoric to be more theory than fact when they "recognize and address" issues by the replacement of disproved theory with just more theory. This is in my opinion more respectable than sticking with the Jones theory of strain-counterstrain than simply sticking the fist in the air and head in the sand and proclaiming that "theory" is more accurate than basic science research on nerve conduction and firing patterns . . . but still lacks true credibility. As an outside observer to your interesting discussion with Barrett (and thank you both, I've learned a lot!), I've been struck more by your feverish defense of McKenzie than Barrett's questioning. I've been wondering not what "axe" Barrett has to grind, but what deep seeded need you seem to have to attack anyone who does not agree with your assessment of McKenzie. In my experience, McKenzie is not like other techniques (e.g. craniosacral therapy, strain-counterstrain, etc). With McKenzie, two learned, evidence based practitioners can disagree about what the studies mean . . . and be justified in their opinions. This is not the case with some other techniques where the research is a little bit more decisive. McKenzie work requires that you roll up the sleeves and get into the statistics and then see if you agree with the conclusions (needless to say, sometimes I do, sometimes I don't). I think this is what's happened here. I suggest that we pick two articles (one pro, one con) and review them together and in depth. We will together share the articles, review the articles, discuss the proposed conclusions, quality of research, and then as a group . . . try to tear apart the studies by close examination of the statistics. Then we'll be able to discuss what's real and assumption in the discussion sections. There's one catch . . . I'd like Barrett to take the lead and defend a pro-McKenzie article, and Mcap to review and defend an anti-Mckenzie article. We all may learn a lot more than we bargained for. Ya'll game?

Andrew M. Ball, MS, PT -> Re: New Website (May 28, 2000 6:25:00 AM)
Here's something to chew on, is it worth the cost of care???? Patients FEEL that they receive better care if they are treated by a PT or DC, but this study shows that they don't actually receive that much of a better benefit. Even the "risk of re-injury" argument does not seem to hold much weight. If a patient wants to pay out of pocket for the extra cost of care, that's fine . . . but ya'll may be missing the point: Given this information, if I were the administrator of an insurance company, I'd seriously consider denying reimbursement for ALL PT and DC low back pain conditions. I'd furthermore consider sueing all participating providers for recovery of the cost of care beyond the cost of a booklet as it can't be argued that anything in addition to it is NOT superfluous and unnecesary . . . boardering on medical malpractice and questionable ethics. The real danger here is not the study, per se, but the fact that most outpatient orthopedic and sports PT's are blissfully ignorant of it. I have a hard time defending my fellow ortho PT's "right to manipulate" in our state, given this reality of self-censorship. OUR PROFESSION NEEDS TO AWAKEN TO THIS STUFF!!! Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med 1998 Oct 8;339(15):1021-9 BACKGROUND AND METHODS: There are few data on the relative effectiveness and costs of treatments for low back pain. We randomly assigned 321 adults with low back pain that persisted for seven days after a primary care visit to the McKenzie method of physical therapy, chiropractic manipulation, or a minimal intervention (provision of an educational booklet). Patients with sciatica were excluded. Physical therapy or chiropractic manipulation was provided for one month (the number of visits was determined by the practitioner but was limited to a maximum of nine); patients were followed for a total of two years. The bothersomeness of symptoms was measured on an 11-point scale, and the level of dysfunction was measured on the 24-point Roland Disability Scale. RESULTS: After adjustment for base-line differences, the chiropractic group had less severe symptoms than the booklet group at four weeks (P=0.02), and there was a trend toward less severe symptoms in the physical therapy group (P=0.06). However, these differences were small and not significant after transformations of the data to adjust for their non-normal distribution. Differences in the extent of dysfunction among the groups were small and approached significance only at one year, with greater dysfunction in the booklet group than in the other two groups (P=0.05). For all outcomes, there were no significant differences between the physical-therapy and chiropractic groups and no significant differences among the groups in the numbers of days of reduced activity or missed work or in recurrences of back pain. About 75 percent of the subjects in the therapy groups rated their care as very good or excellent, as compared with about 30 percent of the subjects in the booklet group (P<0.001). Over a two-year period, the mean costs of care were $437 for the physical-therapy group, $429 for the chiropractic group, and $153 for the booklet group. CONCLUSIONS: For patients with low back pain, the McKenzie method of physical therapy and chiropractic manipulation had similar effects and costs, and patients receiving these treatments had only marginally better outcomes than those receiving the minimal intervention of an educational booklet. Whether the limited benefits of these treatments are worth the additional costs is open to question. Respectfully, Drew

mcap -> Re: New Website (May 30, 2000 8:11:00 AM)
Drew: As many of you know - I am certainly no McKenzie purist and I have already reviewed the Cherkin article in a different thread. My NYC spinal disorders study group frequently discusses the shortcomings of the method and the theory. I do defend the method however because, as you pointed out, they are the only ones attempting to do research. They are out there so they are an easy target. Let someone else step up and we will see what happens. Notice that my original thread had nothing to do with McKenzie and someone else used the opportunity to take a shot. That's why I steped up. As for your assessment of McKenzie research - I feel you are a little off base. Biased publications?? The study mentioned was published in Spine along with many other studies. Yes....PT has had very little to offer over natural history. There is some evidence though. Spine 1995 Feb15;20(4):469-72. "conservatice treatment of actue low back pain. A 5-year follow-upstudyof two mehtods of treatment. In this study - AT 5 YEARS - People who received treatment according to the McKenzie principle 5 years earlier had significantly less recurrences of pain and fewer were on sick leave compared with the subjects who received education in mini back school. The difference was less signficant than at 1 year follow up. A tremendous result....NO. But better than most out there. A biased publication...Spine????? Spine is probably biased in favor of the surgeon if anything!! As for denying care for all LBP patients......wait until the richardson and Jull research comes out, it should make a difference. -Mcap

mcap -> Re: New Website (May 30, 2000 8:21:00 AM)
Many in the low back field say that you will not get a study that is significant until you have a more meaningful diagnosis than "non-specific LBP" They will contend that disc problems should be handled differently than facet, etc. The counter to that is that the Psychosocial factors are more important and that no treatment will prove superior until you deal with this component. I think both camps have some merit in their contentions. I know that the psychosocial factors are critical and I think you need to address them. They may indeed be more important than physical factors. But one shouldn't go to far with this line of thought. It is simplistic and incorrect to say that back problems are psychosocial. First, there is a structural problem in almost each LBP sufferer. First onset LBP people demonstrate no psychosocial similarities or tendencies. Very quickly though psychosocial factors become critical and are promiment in chronic patients. This does not mean that there isn't a continued structural fault though. Researchers are still trying to decide how much of the psychosocial problems are actually caused by the pain as opposed to the opposite. It could be that the pain is causing some of the problems at work, home etc., not the other way around. The jury is still out. We must be opened minded and cautious. On the other hand - I do find that PTs lack of acknowledgment of at least the possiblities of psychosocial factors to be disheartening.

JHall -> Re: New Website (May 31, 2000 6:34:00 PM)
Who cares what the research says?! I must say that I, as a McKenzie trained therapist, follow the pt's symptoms and don't care what the responsible tissue is. Yes, we need to investigate further, but we know less about spine care than we know now. All I know is that when a patient responds and resolves, P.T. is advanced in the mind of the public. What nitpicking! It drives me crazy that we are so concerned with our public image that we forget who the beneficiary is! And this extends to the payment source, which is manned by bean counters who could care less about definitive research. Markets have always been driven by customer demand, and if we, as P.T.'s, provide the supply (fix), our jobs and our future will be secure. I don't care if it's McKenzie, Paris or Purina, if the problem is fixed, it is fixed. Forgive my cynicism after only 5 yrs in the profession.

Andrew M. Ball, MS, PT -> Re: New Website (May 31, 2000 8:07:00 PM)
JHall, Get ready for some Professional Tough Love, ‘cause I’ve got a lot to dish out. I hope that once you calm down from reading this, that you’ll see that as painful as it is to admit these truths to your ego, that you can learn something from this experience and be a better therapist for your patients, AND for the profession that desperately needs you. Please feel free to e-mail me directly if you’d like to discuss this further. That said, brace yourself . . . this is gonna pinch a little bit . . . I could not disagree more. The mere statement, "Who cares what the research says?!" boarders on professional malpractice. You would never take a pill that has not been researched to be safe and effective, you would never try various pills until you found the one that worked, why should physical therapy be any different? "Who cares what the research says?" . . . that's the poisonous attitude that's created the downward spiral that this profession currently faces: Ignorance and apathy to fact. Thanks for that. You've chosen to align yourself with the problem. Patients expect that when they walk into a PT clinic, that their therapist exercises their art from a firm foundation of truth, evidence, and fact. A therapist who can't live up to this moral, ethical, and professional standard, should perhaps consider leaving the profession. In case I'm not being crystal clear . . . Yes, I do consider intentional disregard of evidence to be professional malpractice. Yes I do believe that this poisonous breed of therapist should be expelled from the profession. I just THANK GOD for projected oversupply of PT’s, with any luck it will weed out some of this garbage. This is the very positive unintended result of the expansion of PT education program and oversupply of PT's . . . some PT's who have no business treating patients will not be able to find jobs. Professional expulsion by license revocation will be unnecessary as market forces will eliminate this non-scientific approach to treatment. Long live the new schools. Long live market competition, and Viva Professional Evolution! To be ignorant of evidence based fact is one thing, but to make a point of turning away from it is quite another. I reject your claim that any of your patients "respond and resolve" any faster or more appropriately than if you'd never treated them at all. I reject that you've ever "fixed" a problem beyond natural history. If you did it was dumb luck. You have no basis for any comparison AND you've told me this to be true by your statement "Who cares what the research says?!" By your own admission of self-censorship to research, you have no idea if the techniques that you are using are more effective than if you've done nothing at all. Hell, if I were your patient I'd sue under malpractice law for my money back . . . and legal precedent strongly suggests I'd win. Consider that. The research suggests that NO APPROACH is really all that more effective than no treatment at all. Yeah, some are slightly better (though not statistically significantly so) than others. No treatment would be far more cost effective anyway. If you are truly able to get your patients to "respond and resolve" beyond natural history, well congratulations . . . you're the only one and we'd love to know your secret. Bean counters would not be a problem if you’d truly come up with a program that’s more effective AND more efficient than any other technique. If PWB-GT is any indicator, by the way, the two usually go hand in hand. Furthermore, the bean counters tend to respond to techniques that produce significantly better outcomes in less time. Therapists who modify their treatment approach as a function of evidence aren’t having much of a problem with this . . . why do you suppose that you are??? Finally, your charge that I’ve forgotten that the patient is the true beneficiary is disgusting . . . though I feel that you should seriously consider heeding some of your own advice. I'd submit that it's YOU who's forgotten who the beneficiary is. You've deluded the patient into thinking that you’re helping them, but without a foundation of knowledge behind you (your admission)you have NO IDEA if that's what's happening, you've likely done no more than taken money from the patient for little more than smoke, mirrors, and clinical guessing. Sounds like the true beneficiary (at least financially) here is YOU . . . not the patient. There're a word for that I think . . . oh yes . . . Insurance Fraud. I'd submit that the disregard for science attitude and, and not the "pesky nitpicking" about progressing our profession to and evidence-based science is the true reason that we are in crisis as a profession. Drew [This message has been edited by Andrew M. Ball, MS, PT (edited June 01, 2000).]

mcap -> Re: New Website (June 1, 2000 6:47:00 AM)
JHall: I can see your point of view. It is a common one throughout the profession. I must disagree however and I think that perpetuation of this attitude is extremely detrimental to our profession! I am a credential McKenzie therapist. I have seen with my patients what appears to be almost miraculous results at times. But this is no different from the claim of many other PTs or DCs or others. The point is that none of really know if we are helping until the research is out. The placebo possibilities are tremendous. That point aside....I think you are ignoring other realities. First, how receptive are your local physicians to the McKenzie method. I have met Diplomates who meet with MDs all the time who neither know of the method nor care!!! Is this laziness on their part.....sometimes. But it more reflects the lack of support. One good study that clearly shows efficacy published in JAMA, NEJM, or Spine would make all the difference. Meanwhile, I have people trying to cut off therapy based on the Cherkin study. We are dependent on MDs for referrals and a lack of research is killing us!! Another problem.........you ask if we care about our patients. The question is "do you care?" Do you care enough to look beyond short term benefits. Any therapist who cares about their patients will ask themselves is this really helping in the long run? Is this the best use of their limited health care resources?? AND.....in the long run....could our interventions actually make them worse. In some LBP patients....by setting up an expectation of cure and then failing them we are actually exacerbating their condition and disability behavior. As for suppy and demand.....where is the demand??? How many patients ran to their congressmen when the PPS was put into effect. How many patients are complaining to their insurance companies about reduced reimbursement. As the lack of research continues and referrals continue to decline, our loyal patients will do nothing while the patients of chiropractors storm the legislative gates. The only way out of the upcoming crisis is to prove ourselves. In some cases, we have. But we are way behind in other areas. respectfully submitted, Mcap

JHall -> Re: New Website (June 1, 2000 9:36:00 AM)
Boy, I sure didn't mean to stir anything up! I was being extremely sarcastic after a particularly bad day. I apologize. Thank you Andrew and Mcap for a most eloquent response that I will certainly use to educate students and other therapists. I'm fortunate to work in a clinic where evidenced-based practice is seen everyday. We frequently challenge each other regarding treatment plans and methods, according to the latest research and investigations. Once again, I apologize for venting inappropriately in this forum.

Andrew M. Ball, MS, PT -> Re: New Website (June 1, 2000 9:45:00 AM)
JHall, Great! I was thinking that you were being sarcastic, but I wasn't sure, that's why I sent you a personal e-mail warning you of what was to come. We've gotten a little off topic though. Are we going to look at some outcome studies or what?

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